CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

DEPART!'VIENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA ()(2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
050589 B. WING 0510512011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
PLACENTIA LINDA HOSPITAL 1301 ROSE DRIVE, PLACENTIA, CA 92870 ORANGE COUNTY

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION

PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS-
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFE.RENCED TO THE APPROPRIATE DEFICIENCY)

The following reflects the findings of the Department \~

The plan of correction is prepared in
of Public Health during an inspection visit: 0
compliance with federal regulations and is
intended as Placentia-Linda Hospital's (the •
"hospital") credible evidence of complianc·e. The
Complaint Intake Number: submission of the plan of correction is not an
CA00265360- Substantiated admission by the facility that it agrees that the ,\
citations are correct or that it violated the law.
Representing the Department of Public Health:
Surveyor ID # 21262, HFEN Organization Minutes:
The confidential and privileged minutes are being
retained at the facility for agency review and
The inspection was limited to the specific facility verification ifrequired.
event investigated and does not represent the
findings of a full inspection of the facility. Exhibits:
All exhibits including revisions to Medical staff
Health and Safety Code Section 1280.1(c): For Bylaws, reviewed/revised or promulgated policies
and procedures, documentation of staff and medical
purposes of this section "immediate jeopardy"
staff training/education are retained at the facility
means a situation in which the licensee's for agency review and verification upon request.
noncompliance with one or more requirements of
licensure has caused, or is likely to cause, serious
injury or death to the patient.

DEFICIENCY CONSTITUTING IMMEDIATE Policy & Procedures:

JEOPARDY The CA Regional Compliance Officer and Tenet ;
Legal Department reviewed the Hospital's ,....__,' Apri121 ,
T22 DIV5 CH1 ART3-70203(a)(2) Medical Service Standards of Conduct Booklet along with the c:::::::.· 201 I
Internal Reporting of Potential Compliance Issu~
General Requirements
Policy. An educational presentation was created=
(a) A committee of the medical staff shall be using both source documents which includes a :::;
assigned responsibility for: focus on mandatory and timely reporting ofactu~
(2) Developing, maintaining and implementing and/or potential events such as sexual abuse to c::;)
written policies and procedures in consultation with hospital administration and/or the Ethics Action ;
other appropriate health professionals and Line. The Ethics Action Line is a manned phontry
administration. Policies shall be approved by the line that is available 24 hours a day, 7 days a we&S
This presentation was used to educate both the ~
governing body. Procedures ·shall be approved by
staff and anesthesiologists. ·
the administration and medical staff where such is ~
appropriate. en

Event ID:2PIL 11 9/28/2011 2:19:35PM

TITLE (X6) DATE

cce>
\n)l deficiency statement endl ll with an asterisk (•) denotes a deficiency which the Institution may be excused from correcting providing it Is determined
hal other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date
•f survey whether or not a plan of correction Is provided. For nursing homes, the above findings and plans of correction are dlsclosable 14 days following
he data these documents are made available to lhe facility. If deficiencies are cited, an approved plan of correction Is requisite to continued program
•articlpation.

Hate-2567 1 of7
CAIJFO.RNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH
STi\TEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA ()(2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
050589 B. WING 05/05/2011
NAME OF PROVIDI;R OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
PLACENTIA LINDA HOSPITAL 1301 ROSE DRIVE, PLACENTIA, CA 92870 ORANGE COUNTY

()(4) IP SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

Continued From page 1 Training:

T22 DIV5 CH1 ART3-70213(a) Nursing Service
The CA Regional Compliance Officer educated
100% ofthe OR staff regarding mandatory and _,May 16,
Policies and Proce.dures timely reporting of actual and/or potential events ~ 2._i2011
(a) Written policies and procedures for patient care such as sexual abuse on May 4, 20 II and May 16, 3
shall be developed, maintained and implemented by 2011. This information has been added to new !:::::>_
the nursing service. employee orientation and annual employee 7~~
reeducation. TheCA Regional Compliance Officer! __,
The above regulations were NOT MET as evidenced educated I 00% of anesthesiologists on staff on \ .."?
mandatory and timely reporting of actual and/or
by;
potential events such as sexual abuse on May 16, , -o
2011. ::.3
Based on observation, record review, and staff
C...'
interview, the hospital's medical and nursing Monitoring:
services failed to Implement current Policies and All reports of sexual abuse will be referred to the
Procedures (P&P) including the hospital's Hospital risk manager and counsel for
investigation. The Tenet Ethics Action Line is
Standards of Conduct for reporting of physician
monitored 24 hours a day, 7 days a week. All
misconduct to the administration. The failure of the compliance and patient care issues are referred
medical and nursing staff to report and the immediately to the hospital compliance officer for
consequent failure of the hospital to investigate an investigation, who will involve administration as
allegation of a witnessed sexual assault by medical appropriate.
doctor 2 (MD) resulted in a subsequent sexual
assault of Patient 8 ·by MD 2 and an ongoing threat
Responsible Person(s):
of sexual assault to surgical patients by MD 2 over
CA Regional Compliance Officer
a period of approximately one year. Director of OR

Findings; Disciplinary Action:

Non-compliance with corrective action by hospital
On 4/8/11, the hospital's Clinical Quality staff will result in immediate remediation and
Improvement (CQI) Director delivered a letter of a
appropriate disciplinary action in accordance with
the hospital's Human Resources policies and
sexual assault allegation to the local office of the procedures.
Department of Public Health, Licensing a(l.d
l !'' "c:atutt Program. The letter showed that on Medical Staff members demonstrating non-
compliance with corrective action will be referred
l
1, hospital administration was notified that on
1a hospital transporter believed she for peer review in accordance with Medical Staff
witnessed an anesthesiologist fondle t~e breast(s) bylaws, as appropriate. ·
of a female patient vnder anesthesia for an
outpatient surgical procedure.

Event ID:2PIL11 9/28/2011 2:19:35PM

\BORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

1ny deficiency statement ending with an asterisk(") denotes a deficiency which the Institution may be excused from correcting providing it Is deterroined
~at other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date
•f survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following
1e date these documents are made available to the facility, If deficiencies are cited, an approved plan of correction Is requisite to continued program
•articipa\ion.

ltate-2567 2 of7
 CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

Sl/\TEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
050589 B. WING 05/05/2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
PLACENTIA LINDA HOSPITAL 1301 ROSE DRIVE, PLACENTIA, CA 92870 ORANGE COUNTY

(X4) 10 SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (XS)

PREFIX (EACH DEFICIENCY MUST BE PRECEEDEO BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

Continued From page 2

On 4/11/11 at 0900 hours, review of the hospital's

P&P on Sexual and Other Unlawful Harassment
showed, "Any employee who encounters an
incident of alleged sexual or other unlawful
harassment should promptly report the matter to
his or her supervisor. If the supervisor is unavailable
or the employee believes it would be inappropriate
,.,._,
~....;':':)

to contact the supervisor, the employee should ........

~- ~

immediately contact the Human Resources c:::J

C?
Department. Employees may raise concerns and --1
make reports of unlawful harassment without fear of ~-·
C:J
reprisal."
.
I -o
The policy applied to all . employees, including ::;3
supervisors, managers , department w
heads/directors, and physicians, whether or not
employed by the hospital. Anyone engaging in
sexual or other unlawful harassment would be
"' (}1

subject to corrective action, up to, and including,

termination of employment.

On 4/11/11, further review of the hospital's

Standards of Conduct, under Positive Physician
Relationships, showed inappropriate behavior by an
employee would be investigated by Human
Resources representative, and an appropriate
medical staff committee would investigate
inappropriate behavior by a physician. If anybody
was aware of any behavioral issues, that person
should contact the hospital compliance officer or
the Ethics Action Line.

On 4/11/11 at 1005 hours, Transporter 1 was

interviewed to describe the event she witnessed on

Event ID:2PIL11 9/28/2011 . 2:19:35PM

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (•) denotes a deficiency which the Institution may be excused tram correcting providing it Is determined
that other safeguards provide sufficient protection to the patients. Except for nursing homes, lhe findings above are disclosable 90 days following the date
of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following
the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program
participation.

State-2567 3 of7
 CAPFO~NIAHEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
050589 B. INNG 05/05/2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
PLACENTIA LINDA HOSPITAL 1301 ROSE DRIVE, PLACENTIA, CA 92870 ORANGE COUNTY

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) •TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

Continued From page 3

11. Transporter 1 described the
responsibilities of her job which was to transport
patients for surgery to the operating room (OR) and
to transport the patient after surgery to the recovery
room. At approximately 1700 hours on - 11, she
........~
wanted to inquire from the anesthesiologist (MD 2) .._.'
=·
if the operating team was ready for the next surgery ...-"

patient. Transporter 1 approached the back door of

. c::>
C-::l
--1
the OR. The back door was closest to MD 2.
Looking through the glass window of the back door, ~
0
she saw the circulating nurse (RN 2) charting near
the main door of OR Suite E that led to the hallway. -o
The surgical technician (ST) and the surgeon were . 3
standing at the foot end of the OR table still w
performing a surgical excision of hemorrhoids.
Patient B's legs were spread apart and raised up in
r":?
i:.f1
stirrups to be able to perform the surgical
procedure. MD 2 was standing at the head part of
the OR table with his back towards the back door.
A surgical barrier drape, located over Patient B's
abdomen, separated MD 2 from the sterile surgical
field, and provided a visual barrier from the surgeon
and the ST. What caught Transporter 1's attention
was Patient B's brea~ts were exposed, with MD 2's
hands on top of the patient's chest.

Transporter 1 decided to approach the main door of

the OR and asked RN 2 instead when the operating
team was ready for the next patient. She
approached the back door for the second time.
Looking through the glass window of the back door,
again she saw MD 2's hands, behind the surgical
barrier drape, on top of Patient B's exposed breasts
while the surgical team was occupied finishing the
surgery on the other side of the barrier drape.

Event ID:2PIL 11 912812011 2:19:35PM

.ABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TilLE (X6) DATE

Any deficiency statement ending with an asterisk (') denotes a deficiency which the Institution may be excused from correcting providing it Is determined
thai other safeguards provide sufficient protection to the palients. Excepl for nursing homes, the findings above are disclosable 90 days following the date
of survey whether or not a plan of correction is provided. For nursing homes, the abo-;e findings ~nd plans or correction are disolosable 14 days following
the date these documents are made available to the facility . If deficiencies are cited, an· approved plan of correction is requisite to continued program
participation.

State-2567 4 of7
 CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH

STAli:MENT QF DEFICIENCIES (X1) PROVIOERJSUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (XJ) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
050589 B. WING 05105(2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
PLACENTIA LINDA HOSPITAL 1301 ROSE DRIVE, PLACENTIA, CA 92870 ORANGE COUNTY

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS· COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

Continued From page 4

Per Transporter 1, she reported the event to

~ltal Administration the following Monday,
- 11. Transporter 1 met with the Chief
Anesthesiologist and other members of the medical
staff. MD 2 was taken off the surgery schedule on
- 11 however MD 2 was also practicing at other
hospitals. The sexual assault allegations for MD 2
were not reported to the police by Hospital
Administration until 4/11/11. Patient B was notified
of the allegations on - 11.

During an interview with the Chief Anesthesiologist,

on 4/11/11 at 1230 hours, it was revealed the
allegation about MD 2 was not the first one reported
to him. Approximately a year ago, RN 1 had
reported to him that ST 1, the surgical technician
who assisted on the procedure, witnessed MD 2
touch a female patient's genitals while pertorming a
femoral nerve block (a technique to anesthetize the
lower extremity). The Chief Anesthesiologist,
wanting more concrete evidence, opted to monitor
MD 2's pertormance for any further sexual
allegations. The incident was not reported to the
medical staff and/or administration by RN 1 or the
Chief Anesthesiologist as per the hospital's
standards of conduct. MD 2 was not confronted
about the incident. The alleged first victim was not
notified because the witness, ST 1, was uncertain
of the patient identity ahd the event date. RN 1 and
ST 1 were asked by the Chief Anesthesiologist to
monitor MD 2 during subsequent surgical cases
although there was no guarantee they would be the
staff assigned to the surgical cases in MD 2's room
every day.

Event ID:2PIL 11 9/28/2011 2:19:35PM

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk(*) denotes a deficiency which the institution may be excused from correcting providing It Is determined
that ofher safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date
of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following
the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program
participation.

State-2567 5 of 7
 CALIFORNIA H~LTH AND HUMAN SERVICES AGENCY
DEPARTMEr·n OF PUBLIC HEALTH

STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIER!CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
ANb PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
: A. BUILDING
050589 B. WING 05/05/2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
PLACENTIA LINDA HOSPITAL 1301 ROSE DRIVE, PLACENTIA, CA 92870 ORANGE COUNTY

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEEDEO BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIA1E DEFICIENCY) DATE

Continued From page 5

On 4/11/11 at 1300 hours, ST 1 was asked about

the first allegation. She stated during the
.--.:>
performance of a femoral nerve block on an 18-year c;_"')

old female patient, she witnessed MD 2 touch the ~

0
patient's vagina in an inappropriate way. ST 1 was
unsure if what she saw was part of the normal
:3
procedure. The incident bothered her so she told .....
C'
RN 1 but claimed she remained uncertain of what
she saw, who the patient was, and when It
happened.

On 4/11/11 at 1417 hours RN 1 was asked what

she did after ST 1 had told her of the first allegation
about MD 2. She stated she promised ST 1 to be
quiet about the incident but felt guilty so she
revealed it to the Chief Anesthesiologist Like ST 1,
she was told to continue monitoring MD 2 for any
further allegation. The Incident was not reported to
the hospital administration, the Human Resources
Department or the Ethics Action Line, · as per the
hospital's policy and/or the hospital's standards of
conduct.

The hospital failed to follow their P&P on reporting

unlawful sexual conduct/harassment. As a
consequence, there was no investigation done of
the first sexual allegation about MD 2 and/or
corrective action taken to prevent future
occurrences. These failures resulted in a
subsequent sexual assault of Patient B by MD 2
and exposed surgical patients under anesthesia to
the ongoing threat and likelihood of sexual assault
by MD 2.

Event ID:2PIL 11 9/28/2011 2:19:35PM

.ABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (•) denotes a deficiency which the instilution may be excused from correcting providing it is determined
that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the dale
of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following
the date these documents are made available to the facility. If deficiencies ere cited, en approved plan of correction Is requisite to continued program
participation.

State-2567 6 of7
 CALl FORNI,\ HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH
STAT£MENT OF DEFICIENCIES (X1) PROVIDERISUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
050589 B. WING 05/05/2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
PLACENTIA LINDA HOSPITAL 1301 ROSE DRIVE, PLACENTIA, CA 92870 ORANGE COUNTY

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS· COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DEFIC IENCY) DATE

Continued From page 6

These failures, jointly or separately, are
deficiencies that have caused, or are likely to
cause, serious injury or death to the patient and
therefore constitutes an immediate jeopardy within
the meaning of Health and Safety Code Section
1280.1 (c).

This facility failed to prevent the deficiency(ies) as

described above that caused, or is likely to cause,
serious injury or death to the patient, and therefore
constitutes an immediate jeopardy within the
meaning of Health and Safety Code Section
1280.1 (c).

Event ID:2PIL11 9/28/2011 2:19:35PM

.ABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk(') denotes a deficiency which the Institution may be excused from correcting providing It is determined
that other safeguards provide sufficient protection to the patients. Except for nursing homes. the findings above are dlsclosable 90 days following the date
of survey whether or not a plan of correction Is provided For nursing homes, the abo~e findings and plans of correction are disclosabte 14 days following
the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program
participation.

State-2567 7 of7